Breast reconstruction following mastectomy surgery aims to address the psychological and emotional impact of losing one’s breast. We do this by rebuilding and restoring form and appearance while simultaneously assisting with maintaining breast symmetry and balance.
Who is a good candidate?
We think that women who have early stage breast cancers and have previously had or are undergoing surgery that alters the appearance of their breast are good candidates for breast reconstruction. Women need to have realistic expectations regarding scar patterns and anticipated final appearances.
How is the procedure performed?
We perform breast reconstruction procedures in a hospital under general anesthesia. A single breast can be reconstructed or both breasts in the case of bilateral mastectomies. There are two major categories of breast reconstruction: use of breast implants and use of a woman’s own body tissue.
Implant-based reconstruction can be done in one stage, although more commonly it is performed as a two-step process. When a mastectomy is performed, the skin that remains behind is not able to tolerate excessive stretch or tension. Because of the need to ensure safe and predictable healing of the breast tissue, a temporary device called an EXPANDER is placed into the pocket where the breast tissue once was. The expander is stabilized by being placed under the chest muscle and may incorporate some type of absorbable mesh to provide additional stabilization and coverage while the overlying breast skin and incision are healing. Over the first several weeks following the placement of the expander, we will be adding a saline solution to the expander allowing the breast to develop more shape and creating a pocket for the eventual permanent implant. Once the expander has been fully filled, it is exchanged for a permanent implant that is much softer and feels more like natural breast tissue than the firm expander. Nipple reconstruction and tattooing of the areola are performed on the reconstructed breast mound as adjunctive procedures following placement of the permanent implant.
A woman’s own body also commonly serves as an excellent option for breast reconstruction. TRAM flap operations involve use of lower abdominal skin and fat, and this tissue is transferred from its original location and placed into the pocket where the breast was prior to mastectomy surgery. This operation has variability in the manner in which the tummy tissue is transferred and can be tunneled up under the upper abdomen into the breast pocket while leaving its original blood supply intact (conventional TRAM flap) or can be placed in the breast pocket without the need for such tunneling by dividing the original blood vessels and reconnecting them to new blood vessels within the breast pocket using microsurgical techniques (free TRAM flap). This procedure leaves the appearance of having had a tummy tuck along the abdomen and can create a breast mound that looks and feels very similar to natural breast tissue.
Additionally, a woman may be a candidate for use of her back tissue, or a Latissimus Dorsi flap. During this procedure, the back muscle (with or without some overlying skin, based on individual need) is swung around from the upper back into the breast pocket via a tunnel created just beneath the armpit area. This type of reconstruction often also incorporates the use of an implant or an expander to provide the necessary volume to restore breast shape.
What is the post-operative recovery?
With implant based reconstruction, you will stay a night or two in the hospital. It will take a week or two to become more fully engaged in activities of daily living. TRAM flap reconstruction and Latissimus flap reconstructions are more extensive operations, therefore the recovery is longer. We will have you stay in the hospital 3-5 days and it typically takes several additional weeks to make a complete recovery.
What can I expect for results?
Our goal in breast reconstruction is to restore the shape and appearance of a woman’s breast. We want you to feel more balanced and whole both in clothing and out of clothing. Breast reconstruction consistently provides reliable satisfaction outcomes for women regardless of the technique that a woman chooses. The reconstructed breast is soft and efforts are made to optimize symmetry so that both breasts have as similar a look as can be achieved. Despite the excellent options and results that can be achieved, very few breast reconstructions will look as natural and unaltered as the original breast did prior to surgery. Scars exist on the reconstructed breast that alter the original appearance, and fine tuning of the initial operation may be necessary to achieve optimal results.
Are there any potential complications?
Like any operation, there can be complications. The most common issue we see following implant reconstruction is a collection of fluid inside the breast pocket around the implant. Drains are always used at the initial operation, but fluid can continue to accumulate following removal in certain cases. In most cases, these fluid collections can be managed conservatively, but some instances require drain replacement or revision surgery. Bleeding and infection are rare complications that require prompt treatment to ensure predictable healing. Breast implants can rarely develop heavy scar tissue that prevents a natural feel and look (capsular contracture) and surgery to release this scar is required to address this finding. Additionally, implant position may drift or settle in a manner that produces an undesirable appearance; revision surgery to address this concern may be necessary based on the extent to which this occurs.
Flap reconstruction involves surgery at two locations: the breast and the area from which the flap was transferred. Healing and scaring are usually predictable and efforts are made to keep scars in aesthetic locations to minimize an unfavorable donor site appearance. When tissue is transferred from one location to another, success is predicated on maintenance of healthy blood supply of the transferred tissue. On occasion, a portion of the transferred tissue may have altered blood supply that results in areas of poor healing or scarring. Depending on the extent of this area, revision surgery may be necessary. In severe case, the entire transferred tissue may have poor blood supply and exploratory surgery to assess blood flow issues may be necessary. Fortunately, these type of complications are very infrequent and are monitored and observed during the early period of the stay at the hospital.
Are there additional relevant considerations regarding this procedure?
- Can I have breast reconstruction at a later point if I choose to not have it done at the time of my mastectomy? Absolutely. Breast reconstruction can be performed at the time of the mastectomy (immediate reconstruction) or at any point after the mastectomy has been completed (delayed reconstruction). It is generally agreed that immediate reconstruction provides superior aesthetic results when compared with delayed reconstruction due to preservation of natural anatomic landmarks and absence of scar tissue that impacts delayed reconstruction. However, many women are not candidates for immediate reconstruction or choose to delay their reconstruction for various reasons. Implant-based reconstruction and flap-based reconstruction techniques can be performed on patients who are undergoing immediate or delayed reconstruction.
- How does radiation and chemotherapy affect my need for breast reconstruction? Chemotherapy typically has very little direct impact on breast reconstruction results. Its major direct impact is on the timing of additional operations necessary to complete the reconstruction. Specifically, replacement of the expander with a permanent implant is usually delayed until a month or so after chemotherapy is complete to allow an individual’s immune system to recover and minimize healing problems during the post-operative period. Radiation does, however, have a much more significant negative impact on all aspects of breast reconstruction. Implant reconstruction that undergoes post-operative radiation has a higher likelihood of capsular contracture and may feel less soft as a result of the scarring caused by the treatment. Further, in cases of delayed reconstruction where radiation was given over the mastectomy scar, the radiation changes may produce such significant firmness and skin change that attempting to stretch the skin produces too high a likelihood for poor healing and post-operative complications. In this particular setting, a patient is more likely to derive benefit from use of some form of flap reconstruction to replace the previously scarred and radiated chest skin. Additionally, radiation will cause significant shrinkage and unfavorable changes to a TRAM flap reconstruction, and in settings where TRAM reconstruction is anticipated along with post-operative radiation therapy, reconstructive surgery may best be performed in a delayed setting. These complicated algorithms and scenarios will all be thoroughly discussed by Dr. Grotting and Cohn during the consultation process to come up with a reconstructive plan that provides the most ideal long-term result for you.
- After the initial reconstruction, what type of “fine-tuning” operations are necessary? In many cases, patients benefit from the addition of fat grafts placed around portions of the breast implant to soften the look of transition areas or to add volume to areas where the flap did not restore volume completely. Further, liposuction may be necessary to assist with post-operative shaping and adjustment may be required in flap or implant position to provide optimal results. Most patients do not require these procedures, but for those that do, the procedures are relatively minor compared to previous surgical intervention.
- What if I need surgery on my other breast to create balance and symmetry? Fortunately, insurance companies provide coverage for both reconstruction of an absent breast as well as surgery on the opposite breast to assist in providing long term symmetry and balance. Based on the appearance of the opposite breast, breast reductions, breast lifts, or even a breast implant may be beneficial to produce an ideal outcome and result.
- What if I have a deformity of my breast that resulted from a lumpectomy? Breast reconstruction does not only produce excellent results in cases of mastectomies. Lumpectomies followed by radiation may produce contour deformities that lend themselves to techniques like fat grafting to restore volume and improve scar quality. These procedures are also typically covered by insurance and are individualized based on the specific deformity or problem.
- What if I am not sure I want reconstruction? Can I come in for information gathering and not commit to surgery? Absolutely. Dr. Grotting and Dr. Cohn have a passion and long-standing commitment to breast cancer patients and ensuring that all patients get educated about options available to them. No operation is standard for any type of patient, and the best result and experience comes from ensuring that our patients are well-informed and understand all aspects of their surgical options.